QIP protocols leads to fall in infection rates

Hospital readmission rates dropped by 75 percent and surgical-site infections declined by 60 percent after changes in patient education, discharge planning and pre-operative procedures, according to researchers from Stanford University. The research was presented at the 30th Annual Meeting for the American Society for Metabolic and Bariatric Surgery (ASMBS) during ObesityWeek 2013, the largest international event focused on the basic science, clinical application and prevention and treatment of obesity. The event was hosted by the ASMBS and The Obesity Society (TOS).

In 2008, the national benchmark for 30-day readmissions to the hospital after bariatric surgery was 5 percent; readmissions at the Stanford program were 8 percent. By 2012, the readmission rate at Stanford had fallen to 2 percent. Within the same period, the rate of surgical-site infections went from 2.5 percent to 1 percent, the national average.

“The study demonstrates the value of using validated national benchmarking data to identify areas for quality improvement in local bariatric programmes,” said study author Dr John Morton, Director of Bariatric Surgery at Stanford Hospital & Clinics and President-Elect of the ASMBS. “The data prompted us to identify two areas that resulted in improved patient outcomes and a likely reduction in costs. If programmes throughout the country focus on the areas where they diverge from the national standard, bariatric and metabolic surgery is likely to see even further improvements in safety and effectiveness.”

In the Stanford study, hospital readmission and complication rate benchmark data was obtained from one of the precursor programmes (ACS Bariatric Surgery Network) to MBSAQIP. Stanford then implemented targeted solutions against each of these benchmarks.

For readmissions, patient education and discharge planning were emphasised on a daily basis, direct phone numbers for concerns were provided to patients, a registered nurse called each patient at home the first day after discharge, same day appointments were made available to address patient concerns and a clinical decision unit was utilized for 23-hour stays.

Several process improvements were implemented to reduce surgical-site infections including the postponement of surgery and the referral to an endocrinologist if a patient’s HgA1c level, a measure of blood sugar, was greater than 10. In addition, two grams of antibiotics, rather than one, were administered to the patient before the start of surgery.

Results

From 2008 to 2012, there were significant improvements (p=0.05) in both readmissions and SSI. In 2008, the national benchmark for SSI was 1% and at Stanford University it was 2.5% rate. By 2012, the SSI rate fell to 1%. In 2008, the national benchmark for 30-day readmissions was 5% and 8% at Stanford University. By 2012, the 30-day readmission rate fell to 2%.

“The highest quality care in bariatric surgery is occurring at accredited centres,” added Morton, who is also Chief of Bariatric Surgery at Stanford University Medical Center. “These centres demonstrate their commitment to quality by constantly evaluating and re-evaluating what they do and how they do it to provide patients the best care possible. MBSAQIP will play a role in helping them do that by providing evidence-based data that they can act upon. The first national quality improvement project for MBSAQIP will be to decrease 30-day readmissions through the DROP (Decreasing Readmissions through Opportunities Provided) programme.”

In January 2014, the ASMBS and American College of Surgeons (ACS) will launch the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), a programme that establishes national standards for facilities and surgeons performing bariatric surgery.

MBSAQIP calls for a certain level of surgeon experience in terms of the number of procedures performed annually and the submission of patient outcomes data to a national registry, among several other requirements. National benchmarks obtained from the registry will be used as the basis for establishing best practices and recommending quality improvement efforts. More than 700 bariatric programs are already enrolled in MBSAQIP.